﻿<?xml version="1.0" encoding="utf-8" ?>
<TransactionSpecification xmlns="http://tempuri.org/X12ParserSpecification.xsd" TransactionSetIdentifierCode="835">
  <Segment SegmentId="BPR" Usage="Required" Repeat="1"/>
  <Segment SegmentId="TRN" Usage="Required" Repeat="1"/>
  <Segment SegmentId="CUR" Usage="Situational" Repeat="1"/>
  <Segment SegmentId="REF" Usage="Situational" Repeat="1"/>
  <Segment SegmentId="DTM" Usage="Situational" Repeat="1"/>
  <Segment SegmentId="PLB" Trailer="true" Usage="Situational" Repeat="1"/>
  <Loop LoopId="1000A" Usage="Required" LoopRepeat="1">
    <Name>PAYER IDENTIFICATION</Name>
    <StartingSegment SegmentId="N1" Usage="Required" Repeat="1">
      <EntityIdentifier Code="PR"/>
    </StartingSegment>
    <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
    <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
    <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
    <Segment SegmentId="PER" Usage="Situational" Repeat="1"/>
  </Loop>
  <Loop LoopId="1000B" Usage="Required" LoopRepeat="1">
    <Name>PAYEE IDENTIFICATION</Name>
    <StartingSegment SegmentId="N1" Usage="Required" Repeat="1">
      <EntityIdentifier Code="PE"/>
    </StartingSegment>
    <Segment SegmentId="N3" Usage="Required" Repeat="1"/>
    <Segment SegmentId="N4" Usage="Required" Repeat="1"/>
    <Segment SegmentId="REF" Usage="Situational" Repeat="4"/>
  </Loop>
  <Loop LoopId="2000" Usage="Required" Repeat="9999">
    <Name>HEADER NUMBER</Name>
    <StartingSegment SegmentId="LX" Usage="Situational" Repeat="1"/>
    <Segment SegmentId="TS3" Usage="Situational" Repeat="1"/>
    <Segment SegmentId="TS2" Usage="Situational" Repeat="1"/>
    <Loop LoopId="2100">
      <Name>CLAIM PAYMENT INFORMATION</Name>
      <StartingSegment SegmentId="CLP" Usage="Required" Repeat="9999"/>
      <Segment SegmentId="CAS" Usage="Situational" Repeat="99"/>
      <Segment SegmentId="NM1" Usage="Required" Repeat="1"/>
      <Segment SegmentId="MIA" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="MOA" Usage="Situational" Repeat="1"/>
      <Segment SegmentId="REF" Usage="Situational" Repeat="5"/>
      <Segment SegmentId="DTM" Usage="Situational" Repeat="4"/>
      <Segment SegmentId="PER" Usage="Situational" Repeat="3"/>
      <Segment SegmentId="AMT" Usage="Situational" Repeat="14"/>
      <Segment SegmentId="QTY" Usage="Situational" Repeat="15"/>
      <Loop LoopId="2110">
        <Name>SERVICE PAYMENT INFORMATION</Name>
        <StartingSegment SegmentId="SVC" Usage="Situational" Repeat="999"/>
        <Segment SegmentId="DTM" Usage="Situational" Repeat="3"/>
        <Segment SegmentId="CAS" Usage="Situational" Repeat="99"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="7"/>
        <Segment SegmentId="REF" Usage="Situational" Repeat="10"/>
        <Segment SegmentId="AMT" Usage="Situational" Repeat="12"/>

        <Segment SegmentId="QTY" Usage="Situational" Repeat="6"/>
        <Segment SegmentId="LQ" Usage="Situational" Repeat="99"/>
      </Loop>
    </Loop>
  </Loop>
</TransactionSpecification>